Principles Of Oncological Surgery Flashcards by Harrie Long

Why is it important to biopsy as large a section of tissue as possible?

Bigger piece of tissue + better chance of correct diagnosis

Smaller bits of tissue increases risk of sampling error

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What are the advantages of surgical tumour resection?

Immediate cure 
Not carcinogenic 
No toxic effects 
Not immunosuppressive 
Better for large masses

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What are the disadvantages of surgical excision?

Local cure only
Change in cosmesis
Change in function

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What steps do you need to take to plan surgical excision?

histologically diagnosis

Assess extent of local disease

Look for presence of local or distant metastasis

Assess the nutritional status of the patient

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What is the best method to assess the presence of local or distant metastasis?

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Why is it important to assess the nutritional status of the patient before sx?

May want to build nutritional management into treatment plan e.g. feeding tube

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When in the course of disease would you aim to surgically excise a tumour ?

Early

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Which surgery has the best chance of success?

Why?

The FIRST ONE

Anatomy gets distorted by the first sx

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What should not influence decisions relating to margins?

Concerns regarding closure

In practice?

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Where are the most active and invasive parts of a tumour located?

PERIPHERY

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When should biopsy be performed?

If the treatment plan would be changed

type of tx
extent of tx

If owner’s decision would be changed
- tumour type/grade, clinical stage, prognosis

If lesion in difficult area - head + neck, distal limb

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When might biopsy not be indicated?

Mass in thorax

DDx : primary tumour, lung lobe abscess, fungal granuloma
all tx with excisional surgery

Solitary pulmonary nodule
- excisional biopsy - curative (of primary) + diagnostic -
Don’t need to know prior to sx

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Which has a better survival time: an osteosarcoma or a chondrosarcoma?

CHONDROSARCOMA - 3-4 years

Osteosarcoma ~6 months

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When would biopsy not be indicated?

Treatment plan would not be changed

mammary mass excisions
single large lung mass lobectomy

No change in owner’s willingness to treat
- chest wall sarcoma resection

Biopsy is as difficult as sx
- CNS mass lesions, thyroid tumours, small intestine tumours

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Why might you not biopsy thyroid tumours?

Very vascular

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What are the types of biopsy?

Needle
Incisional
Excisional

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What are the types of needle biopsy?

FNA

Core - tru-cut

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What limitations are associated with FNAs?

False negatives common

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What are FNAs good at diagnosing?

MCT, lymphoma

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What issue is associated with core/tru-cut biopsy?

Might just get a lot of necrotic tissue.

What are the types of incisional biopsy?

Surgical
Grab biopsy
Punch biopsy

What should you bear in mind when performing an incisional biopsy?

Biopsy in a way that won’t compromise excision surgery later

E.g. biopsy jaw tumours through oral cavity

Why should you punch biopsy at the edge of a lesion?

To get the transitional zone

How can you reduce contamination when excising a tumour?

Avoid entering the pseudocapsule (contains tumour cells)
Manipulate tumour gently (use atraumatic forceps)
Isolate tumour from body cavity
Resect adhesions between tumour and normal tissue
Lavage the surgery site - removes blood, necrotic tissue, foreign material
Change gloves and instruments

How should you manage the blood vessels during sx?

Reduce blood flow to reduce embolic spread VEINS - prevents venous emboli (still spread via lymphatic ARTERIES - prevents haemorrhage, prevents organ congestion, reduced arterial supply = reduced venous outflow

How can you tell if metastasis to a LN has occurred?

Can ONLY tell for certain by excising the whole LN and using microscopy

When should you remove a regional LN?

LN is positive for tumour and not fixed to another tissue LN is grossly abnormal at sx LN intimately attached to excised tissue Also if associated with therapeutic benefit

When should you NOT remove a regional LN?

If LN fixed to critical adjacent tissue - e.g. Bronchial LNs closely associated with vessels If uncertain as to whether positive for tumour (then biopsy indicated)

What are the types of local metastasis that may surround a tumour?

Satellite metastasis (closer to tumour) Skip metastasis Finger like projection

What are the aims of margins of excision?

Removal of the tumour and a margin of normal tissue

What are typical margins taken?

3-5 cm around, 1 fascial plane deep

What is the pseudocapsule?

A zone of compressed tissue around the tumour. Contains viable tumour cells DO NOT ENTER WHEN EXCISING

When would you consider ‘shelling out’ a tumour?

Very large lipomas between muscle bellies

What is local excision?

Tumour removed through the natural capsule or immediate boundaries

When is local excision indicated?

Benign tumours and NO local invasion E.g. lipoma, histiocytoma, sebaceous adenoma To preserve adjacent tissue E.g. thyroid adenoma or CNS

When is local excision contraindicated?

Local invasion | Malignancy

What is wide local excision?

Tumour removed with substantial margin of normal tissue

When is wide local excision indicated?

Benign tumours / local invasion Malignancy/ limited local invasion

What margins would be indicated for a SCC or benign oral tumour?

1cm

What margins would be indicated for a MCT or ST sarcoma?

2-3cm

When is wide local excision contraindicated?

More invasive malignancies | Higher grade tumours

What is radical excision?

Margins extend into fascial planes undisturbed by tumour growth

When is radical excision indicated?

Malignancy | Local invasion

What are the four types of radical excision?

Radical local Compartmental Muscle group excision Amputation

What is radical local excision?

Tumour removed with extensive margins of tissue including one or two fascial planes beyond gross tumour

When might radical local excision be indicated?

Invasive sarcoma of the abdominal or chest wall Invasive carcinoma of nasal plan up Invasive tumours involving eyelids Invasive orbital/periorbital tumours

What is compartmental excision?

Tumour is removed in an intact anatomic compartment E.g. tumour inside muscle belly —> excise muscle

When is amputation indicated?

Large tumours If radical excision impairs function - e.g. bone/joint Management of recurrences - disturbed fascial planes